Asthma in the young

Understanding asthma, the things that can trigger it, and how asthma is treated, will help you control your child’s asthma so he or she can lead a full and active life. If your child has started showing signs of asthma (eg, wheezing, breathlessness, night-time coughing), consult your doctor. Infants and children under one year may have wheezing that is not necessarily asthma (see below).

When is a wheeze not a 'happy wheeze'?

Many children under one year of age will wheeze or cough because their airways are very small. This does not necessarily mean they have asthma. Most of these children grow out of their wheezy episodes by the time they are three years old. These children are sometimes referred to as 'happy wheezers' and their condition requires little or no treatment. 

One in four will get asthma

However, one quarter of all New Zealand children will develop asthma. It is difficult to pick out the children with asthma from the 'happy wheezers' as there is no clear 'asthma test' for young children.

What is asthma?

When you breathe, air travels into your lungs through your airways. People with asthma have oversensitive airways which react to triggers that do not affect other people. These triggers cause the airways to tighten, partially close up, swell inside and make more mucus. This makes it hard to breathe in and even harder to breathe out. 

Asthma can run in families but not everyone in the family will have it.

How do I know if my child has asthma?

Some signs of asthma in children are:

• coughing, particularly at night and after exercise
• breathlessness
• wheezing (noisy breathing) 
• a tight feeling in the chest.

Talk to your doctor if your child has any signs of asthma. Most children with asthma live healthy lives if their asthma is under control. However, some children may find physical activity difficult or have trouble sleeping due to coughing or asthma attacks. It is important to know as much as you can about your child's asthma so it has the least possible impact on their life. 

Methods to help diagnose asthma in children

• Child Asthma Symptom Diary - Your doctor, nurse or asthma educator can show you how to fill in a Child Asthma Symptom Diary to record your child's symptoms over several weeks. This diary will help clarify whether or not your child has asthma and will help you to understand and gain control of your child's asthma.
• Peak flow meter and Peak flow diary - Children over 6 years may be able to use a peak flow meter to measure how well their lungs are working. Peak flow meters are available free of charge from your doctor. Peak flow measurements should be used in conjunction with a symptom diary.
• Spirometry test - Children over 7 years may be able to take a spirometry test. This is a simple test that can be used to diagnose lung conditions like asthma. The test involves taking a full breath in and blowing into a tube attached to a spirometer machine. The test may be repeated after taking a dose of reliever medication.
• Other lung conditions - If your child has a wet phlegmy cough for over 6 to 8 weeks, talk to your doctor about other possible lung conditions.

Will my child grow out of asthma?

Many children will stop having any asthma symptoms by early adulthood, but may develop other allergic problems such as hayfever. Children with severe asthma are less likely to grow out of it. About one third of adults with asthma did not have asthma as children, but develop symptoms in later life.

The key is controlling asthma well so that it does not stop your child being fit, strong, healthy and happy.

How can I help my child's asthma?

Work as a team - You, your child, your doctor, practice nurse, pharmacist and asthma educator make up a team looking after your child's asthma. See your child's own doctor whenever possible because other doctors will not know their history as well.

Visiting when the child is well will help doctors, nurses and asthma educators check inhaler techniques, update management plans and monitor the difference between good and bad asthma health. If you feel that your child's asthma is still not under control, you can discuss your concerns with your doctor, who may suggest a referral to a paediatrician.

Child Asthma Plan - Ask your doctor for a written management plan to show you what to do when your child's asthma improves or gets worse.

Common asthma triggers

Understand and try to avoid common asthma triggers:

• colds and flu 
• cigarette smoke
• house dust mites (found in all homes, especially in carpets and bedding)
• certain plants
• cats and other furry pets
• emotions
• weather changes
• physical activity.

Ways to avoid asthma triggers

Some ways to help your child avoid asthma triggers are: 

• don't smoke - make your home and vehicle smoke free (auahi kore)
• try to minimise exposure to house dust mites in bedding, soft toys and carpets - for tips see Asthma and house dust mites
• children with asthma should not sleep in the same room as pets - also see Pets and asthma
• if bunk beds are used, children with asthma should sleep on the top bunk
• if your child does has a cold or the flu, watch carefully for signs of asthma and modify his/her medication according to the doctor's advice or your Child's Asthma Plan (your doctor will discuss this with you).

What about food allergies and asthma?

In a small percentage of children, certain kinds of food or drink may make their asthma worse. The foods most commonly associated with food allergy are cow's milk, wheat, seafood, eggs, soy and peanuts. The main symptoms of food allergy are hives, eczema, itching, vomiting, diarrhoea, abdominal pain, nasal congestion and wheeze.

Mild food allergy affecting asthma occurs in around one out of 50 children under the age of two. Most childhood allergies are outgrown by the age of three. If foods that commonly cause allergies are not introduced to a child's diet until they are two years old, they are less likely to develop lifelong allergies.

Contact your doctor before removing a particular food from your child's diet, as it may be important and necessary for healthy growth.

How do asthma medicines work?

There are four main types of asthma medicines:

• preventers
• relievers
• symptom controllers
• combination medicines.

Preventers

A preventer is your child's most important medicine, because it prevents swelling and narrowing inside the airways and reduces the likelihood of an asthma attack.

Preventers work slowly, so your child won't notice any immediate change in how they feel. It is important to never underestimate the effect of preventer medicine. It will help control the health of your child for the months ahead. However, it needs to be taken every day as prescribed to be effective - even when your child is well. Some side effects of preventer medicines include a sore throat, hoarse voice or a fungal infection in the mouth. Your child should wash his/her mouth out after each dose, or have a glass of water or clean his/her teeth, to help prevent any side effects.

Steroid tablets

Sometimes children need to take short courses of steroid tablets (usually prednisone) or steroid liquid (prednisolone) as well as their preventer medication. Oral steroids are very useful in bringing asthma under control quickly. They do this by reducing the swelling of the lining in your child's airways and reducing the amount of mucus produced.

A short course of prednisone is safe with no lasting side effects. The side effects of short courses of prednisone are usually mild. Also see: Steroid tablets

Relievers

A reliever medicine brings short term relief from asthma. It relaxes the tight bands of muscle around your child's airways. This helps air flow in and out more freely.

Reliever medication can be taken to relieve wheezing, coughing or tightness in the chest area. See your doctor or asthma educator if your child is using their reliever more than 3 to 4 times a week, as this means their asthma is not under control.  They may need to start or increase preventer medication, which treats the underlying cause of asthma - swollen and inflamed airways. Some side effects of reliever medicines include mild shaking, headaches, racing heart beat and restlessness. Talk to your doctor if your child experiences these symptoms.

Symptom controllers

A symptom controller is a long acting reliever that can help children who continue to have asthma symptoms despite regular use of a preventer medicine. It is taken twice a day to keep your child's airway muscle relaxed. The effect of each puff lasts 12 hours.

Symptom controllers are used in addition to the preventer inhaler. They do not replace the preventer inhaler, which must be taken at the same time. Symptom controllers should not be used for immediate or emergency asthma relief. Some of the side effects from using this type of inhaler can be mild shaking, headaches, a racing heartbeat or restlessness. Talk to your doctor if your child experiences these symptoms.

Combination inhalers

Combination asthma inhalers contain both preventer and symptom controller medicines in the one device. Combination inhalers must be used every day, even when your child is well.

Combination inhalers should not be used in emergency situations when your child is having an asthma attack (ie. use a reliever inhaler for immediate relief of asthma symptoms). Some of the side effects from using a combination inhaler are mild shaking, headaches, a racing heartbeat, an irritated throat or a fungal infection of the mouth. The sore throat and fungal infection can be prevented by cleaning teeth or rinsing mouth out with water after using the inhaler.

Which inhaler is best for my child?

The type of inhaler used to deliver medicine should suit the age and ability of the child. Your doctor, nurse or asthma educator will discuss the choices, the following is a general guide only.

Under fives

Children under the age of five can use metered dose inhalers (MDIs) with a mask attached to the spacer device - the medicine is squirted from the MDI into the spacer, where it remains suspended for 15 to 30 seconds. This allows time for the child to take six normal breaths through the mask. Often children object to the mask, but most will get used to it in time.

At about two-and-a-half years of age a spacer with mouthpiece, instead of mask, can be tried. Liquid medicines are sometimes prescribed, but they are slower acting and have more side effects than inhaled medicines.

Age five and over

Children in this age group can continue to use their MDIs with a spacer (without a mask), or a dry powder medicine inhaler.

Age 12 and over

There is no need to change medicine or inhaler device unless there is a problem. A breath-activated device can also be used. Checks need to be made to see that the inhaler device is used properly and that the lowest dose is used to achieve good asthma control.

Also see: Puffers and other devices

What about other treatments?

There are many 'complementary' treatments available; however, many have not been tested thoroughly. Complementary medicines and therapies usually refer to treatments that do not use drugs prescribed by doctors.

It could be extremely dangerous to stop your child's usual prescribed treatment from the doctor suddenly. Any change in treatment should always be discussed with your child's doctor.

Children with asthma at school

It is important to discuss your child's asthma with the teacher and school health representative. Explain how they can prevent or recognise symptoms and provide them with a copy of your child's asthma plan to follow in an asthma attack.

Ensure the school has your written permission to give reliever medicine in an emergency and that your contact phone numbers are kept up to date in school records. Check to see if your child's school has an asthma policy in place. The Asthma Foundation can supply schools with a suggested asthma policy as part of its Asthma Friendly Schools programme.

Physical activity is important

Physical activity benefits children with asthma, provided their asthma is well managed. Physical activity is good for the heart, circulation, bones and muscles. Many children with asthma avoid physical activity in case it brings on an asthma attack. Talk with your doctor about the best methods to ensure your child leads an active life.

Some things to discuss:

• use reliever medication before exercise if activity has been identified as an asthma trigger
• avoid exercise on days when the child has asthma symptoms
• long distance running and endurance activities are most likely to cause exercise-induced asthma
• sports with lots of stopping and starting are less likely to cause problems, eg, swimming, tennis, martial arts and most team sports
• warming up before exercise can help. Stretching, running on the spot and increasing fitness can reduce the likelihood of exercise-induced asthma
• exercising in cold dry air conditions may trigger asthma
• flowering grasses or freshly mown grass on sports fields may cause symptoms for some children with asthma
• if the child starts showing signs of asthma, stop the activity immediately and prepare to follow the instructions for an asthma attack (see below).

What should I do in an emergency?

It is important to recognise and treat asthma as soon as possible, so it can be brought back under control.

Remember to follow the A.S.T.H.M.A. steps (Assess - Sit - Treat - Help - Monitor - All ok): 

• ASSESS - Is it mild, moderate or severe?
  -Mild symptoms might include: slight wheeze, mild cough, symptoms when excited or running
  -Moderate symptoms might include: obvious breathing difficulties, persistent cough, difficulty speaking a complete sentence
  -Severe symptoms might include: distress, gasping for breath, difficulty speaking more than one or two words, looking pale and sounding quiet, complaints that the reliever medicine is not working, unresponsiveness.

If the child has severe asthma or is frightened, call an ambulance immediately on 111.

• SIT - Sit down and lean the child forward slightly. Ensure the child's arms are supported by their knees, a table or the arms of a chair.
• TREAT - Treat an asthma attack with up to 6 puffs of a reliever (usually blue) inhaler. If reliever medicine comes in a metered dose inhaler (MDI), use a spacer if possible to gain the maximum benefit of the medicine. Puff the inhaler once into the spacer, while the child takes 6 breaths as normally as possible in and out through the spacer. Repeat the process up to 6 times (with a total of 36 breaths). 
• HELP - If the child is not improving after 6 minutes, call the ambulance (if you haven't already). Remember, puff the inhaler once into the spacer and take 6 normal breaths. Continue to use the reliever inhaler - 6 puffs every 6 minutes - until help arrives. In this situation you will not overdose the child by giving them the reliever every 6 minutes.
• MONITOR - If improving after 6 minutues, keep checking. If necessary repeat doses of the reliever inhaler.
• All O.K. - When the child is free of wheeze, cough, breathlessness, you can let them return to normal activities. If symptoms recur, repeat treatment, rest, and see your child's doctor.

Original material provided by The Asthma Foundation of New Zealand, 2006. Reviewed by everybody, November 2010.